Scholarship Application : iCAN Junior Triathlon Club

This program provides under served, at risk youth an opportunity to participate in the club and its programs.

To get started, fill out the application below.

First Name *

Last Name *

Date of Birth *

/ /

Street Address *

City *

Zip / Post Code *

Home Phone *

Cell Phone

E-mail Address *

School *

Name of Parent or Guardian *

Relationship *

Please explain in a few sentences why you are requesting a scholarship. *

Please tell us why you would like to participate in our program. *

Name *

Relationship *

Phone Number *

Name *

Relationship *

Phone Number *